A fistula is a type of access point that is commonly used in dialysis to direct blood from the patient’s body to the dialyzer. Chronic kidney disease patients are highly dependent on the quality of the fistula for their ongoing treatment. Because the dialysis technician may be tasked with accessing the fistula, it is important to understand how a fistula functions and the precautions that should be taken when preparing patients for treatment. Failure to correctly access the fistula could lead to patient hospitalization.
One of the first things that must happen when an individual develops chronic kidney failure is to have a vascular access point established. This process is very important because human anatomy only allows for adequate access points at approximately 12 locations throughout the body. When an access point has been compromised, it must be repaired or replaced. The fact that there are so few locations where an access point can be established means that each site must be handled with extreme care. Patients who have exhausted their access sites may not be able to continue receiving the treatment they need in order to survive.
The creation of a fistula for dialysis is designed to allow technicians and other members of the treatment team to hook patients up to the machine that performs the filtration process. In most cases, the fistula is accessed using a needle. A needle that has not been placed in the fistula correctly can lead to a failed access point which could place the patient at risk for hospitalization, surgery, extreme illness, amputation, and even death. Since fistula complications account for approximately 25% of all dialysis related hospital stays, technicians will receive extensive training and supervised instruction before being allowed to establish access points independently.
An arteriovenous fistula for dialysis is created through a surgical procedure that involves sewing an artery and a vein together under the skin. The dialysis procedure requires the use of large arteries and veins that are often located deep within the body. In many cases, the surgeon must bring the vein close to the surface of the skin so that it can be accessed with a needle. A fistula is not the only type of access point that may be established, but it is commonly considered the best option because it utilizes normal human anatomy and is located below the skin. Grafts and catheters represent alternative access options, but they are more susceptible to failure from occlusion and create a higher risk for infection.
Individuals who develop renal disease will often have a fistula for dialysis created in advance of beginning the treatment process. The fistula is surgically created so that the connection, also known as the anastomosis, has time to become strong enough for needle insertion. Once the blood vessels have been connected, the pressure from the blood flow will cause the access point to enlarge. The most commonly used location for this type of connection is in the upper arm near the brachial artery and cephalic vein.
Not every patient is eligible to receive a fistula for dialysis. Members of the treatment team must assess each patient individually to determine whether or not they are healthy enough to handle the strain on the heart and blood vessels that a fistula creates. While the fistula is the most desirable type of access point, it reduces the amount of blood flowing to the hand and increases the volume of blood that returns to the heart. Patients must have arteries and veins that are healthy enough to supply the necessary amount of blood to the hand while a fistula is present. In addition, a patient’s heart must be healthy enough to handle the increase in blood flowing through it. Individuals who fail to meet these requirements may be forced to consider alternative options. There are a number of complications that can occur during and after the surgical procedure that creates the fistula for dialysis. Individuals must be prepared to accept other types of access options in the event that a patent fistula cannot be created.
It is unlikely that the dialysis technician will be allowed to access fistulas until after they have acquired extensive training and experience. While it can take awhile for technicians to develop the appropriate level of competency to handle fistula access, they should familiarize themselves with the initiatives that have been developed to increase the use of the fistula for dialysis. The Kidney Disease Outcomes Quality Initiative (KDOQI) established by the National Kidney Foundation (NKF) was the first to establish goals for increasing the use of fistulas in the United States. In 2003, the Centers for Medicare and Medicaid Services (CMS) developed the National Vascular Access Improvement Initiative (NVAII) that sought to increase the use of the fistula for dialysis to greater than 40%. The CMS later renamed the NVAII to the Fistula First Breakthrough Initiative (FFBI) and increased its goal to 66%.
The following are the 13 improvement concepts that are included in the FFBI…
- Routine continuous quality improvement (CQI) review of vascular access
- Timely referral to a nephrologist
- Early referral to a surgeon for “AVF only” evaluation and timely placement
- Surgeon selection based on outcomes, willingness, and ability to provide services
- Full range of surgical approaches to AV fistula evaluation and placement
- Secondary AV fistula placement in patients with AV grafts
- AV fistula placement in patients with catheters, where indicated
- AV fistula cannulation training
- Monitoring and maintenance to ensure adequate access function
- Education for caregivers and patients
- Outcomes feedback to guide practice
- Hospital systems to detect CKD and promote AV fistula planning and placement
- Patient efforts to live the best possible quality of life through self-management
New technicians should carefully observe how experienced professionals access the fistula for dialysis. Technicians must also monitor the fistula during dialysis for signs of infection and wound healing. Additional learning points include fistula evaluation, site cleaning, needle placement, taping, the rule of 6’s, OSHA standards, and much more. As technicians gain experience, they will be better prepared to access the fistula once the supervisor has made the determination that the technician is adequately qualified.
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